Joel Watts, MD, FRCPC, DABPN (Forensic Psychiatry)

It is my pleasure to update you on CAPL’s activities and advocacy in the
past few months. As president of CAPL, I am a member of the Canadian
Psychiatric Association (CPA) Board and this affords us and the CPA the
opportunity to benefit mutually from our combined expertise and influence.

One such example involves a position paper published by the Canadian
Psychological Association earlier in 2018. In it, the authors state that the
Criminal Code should be modified to allow psychologists to be added to the list
of potential court-ordered assessors of Fitness to Stand Trial and Not
Criminally Responsible (NCR). Even though the Criminal Code does not prohibit
them from being named by individual courts currently, they presented many
arguments advocating from them to be explicitly included in the pool of
potential assessors.

As an example of our close collaboration with the CPA, our Board
discussed this issue and then reached out to the CPA Board to discuss a joint
position statement/letter to the federal Minister of Justice. The letter, which
the CPA president, Dr. Wei-Yi Song, and I signed on behalf of our respective
organizations, outlined our concerns about the psychologists’ positions and
proposals, and reassured the government about the current functioning of the
forensic system in Canada.

The following is a summary of the key points we made in our letter:

We respect and recognize the expertise
of our psychologist colleagues and our patients benefit from our ongoing
collaborative working relationship. We noted that many psychologists are
already recognized by courts as experts, including risk assessments and
Dangerous Offender matters. They do also already provide appropriate expert
evidence in non-medically complicated cases of Fitness or NCR.

Legislators should be cautious as about
designating psychologists specifically in the Criminal Code. Courts address
most assessment orders to designated hospitals where psychologists cannot be
the primary responsible clinicians for evaluees.

Only psychiatrists have the requisite
medical training and expertise to conduct complicated assessments, particularly
where the issue is Fitness to Stand Trial and recognition, diagnosis and
treatment of medical and psychiatric illness can be crucial to the legal issue.
Due to the bar being quite high in Canada for individuals to be found Unfit and
therefore serious mental illness being implicated most often, it is in fact
necessary for medically trained physicians to give evidence in cases where a
Treatment Order must be obtained to render an accused Fit again.

Despite concerns raised that delays in
timely completion of Fitness or NCR assessments could caused problems in light
of the Supreme Court decision in R v. Jordan, current canvasing of the major
forensic centres across the country has revealed that these assessments are
being completed within the statutory timelines in the vast majority of cases.
CAPL and the Royal College are aware of some pockets of the country where
significant manpower issues exist but are already involved in recruitment and
training initiatives to ensure adequate forensic psychiatry coverage across the
country.

There would be no cost or time savings
to the system from the psychology proposal due to the need to have
psychiatrists involved in many cases, especially where treatment is an issue.

It does not appear currently that there is any appetite by the
government to modify the Code according to the psychologists’ requests, but we
remain vigilant and will continue to show leadership on this issue, including
asking to speak with parliamentarians if necessary.

CPA also sought CAPL’s counsel when they were invited to submit a
briefing paper to the he House of Commons Standing Committee on Public Safety
and National Security, regarding the government’s proposed Bill C-83: An Act to amend the Corrections and Conditional
Release Act and another Act in November 2018. Those of you who are also CPA
members received notice about this briefing paper and it is available on the
CPA website. In it, we offered support to the
parts of the bill that seek to reduce the use of seclusion in prisons. We also
encouraged the government to ensure that proper oversight of seclusion is left
in place and that the legislation also backs up the measures with appropriate
funding and framework for increased and properly trained mental health staffing
and appropriate environments where seclusion is being used.

In September 2018, CAPL sponsored an Expert Psychiatry Series talk on
capacity issues at the CPA annual conference in Toronto. The talk was
well-received, and thanks to Drs. Booth and Klassen for preparing an engaging
presentation and representing our field so well.

The CAPL Board continues to meet regularly and at the AAPL conference in
Austin on October 2018, several of us met to further our work on developing
CAPL’s operating procedures and policies. This work continued from the year
before and we are closer to completing final edits of these documents. We will
keep you all informed when the CAPL Board finally adopts our policy documents.
This is an important step in ensuring that our future leaders have the proper
tools to guide decision-making and the basic operations of CAPL.

CAPL members Drs. Glancy and Tomita are currently revising AAPL’s
guidelines on prescribing in corrections with a focus on our Canadian
correctional psychiatry practices. We hope that this document will serve as a
resource that practitioners who work in corrections can use and refer to
whenever they need to explain or justify rationale for prescribing in these
difficult environments.

As president, I have the honour to be involved in assessing membership
requests with some regularity. It is gratifying to see that despite our
relatively small number in Canada, we continue to attract so many impressive
and dedicated psychiatrists with formal forensic training, qualifications and
expertise who seek to become CAPL members. Many are new or recent graduates of
Canadian PGY-6 programs or forensic psychiatrists from abroad. It is great to
be able to welcome new members into the CAPL family who will ensure the
healthiness and renewal of our field.

This year’s annual conference
will be held in Montreal; the first time we have visited this vibrant and
exciting city. It is also the first time that we will be holding it a bit later
in the year in the hopes that warmer weather will welcome us from Apr. 28 to
May 1, 2019. Based on what I have seen from the Conference Organizing
Committee, this year’s conference is on track to be one of our best ever, with
engaging pre-conference seminars and mealtime speakers and the return of the
our social events (remember the pub event in Victoria last year?!) We hope to see you all there.

Lastly, the Board would like to
remind members that elections for CAPL Board director positions will occur in
2020 (at the annual conference in Banff) as many current directors will be at
their term limits (myself included). We will be seeking enthusiastic and
committed CAPL members to step up and contribute to CAPL’s leadership in the
future. Please contact Nominating Committee Chair, Dr. Johann Brink, at
capl@cpa-apc.org if you are interested in being nominated for director of the
Board or would like to nominate another CAPL member willing to take on this
role in 2020. You may also consult the CAPL bylaws available on our website for
information about the roles of CAPL Board directors and term limits.

Greetings From Your RCPSC Forensic Psychiatry Specialty
Committee

Brad Booth, MD, FRCPC, DABPN (Forensic Psychiatry)

Chair, Specialty Committee in Forensic Psychiatry

As a reminder, CAPL as the
national specialty society has a vital link to your Royal College specialty
committee, in existence since December 2009.
At the specialty committee we work in close collaboration with CAPL and
our profession nationally to establish training standards in the specialty,
develop examinations, ensure appropriate quality training is occurring and
certify individuals holding themselves out as forensic psychiatrists.

In addition to the core members,
each of the program directors from the accredited programs serve as non-voting
members. Since the formal recognition of
the specialty in April 2011, there has been a total of seven schools come
online with accredited programs:

University

Program Director

Next Regular Accreditation
survey

University of British Columbia

Dr. Todd Tomita

Spring 2020

University of Alberta

Dr. Lenka Zedkova

Fall 2023

University of Saskatchewan

Dr. Azaad Baziany

Fall 2023

McMaster University

Dr. Yuri Alatishe

Fall 2022

University of Toronto

Dr. Lisa Ramshaw

Fall 2020

University of Ottawa

Dr. Michelle Mathias

Spring 2024

Université de Montréal

Dr. Jocelyne Brault

Spring 2021

Since the formalization of the
subspecialty in 2011, 164 psychiatrists in Canada have successfully been
certified as forensic psychiatrists. The national distribution is quite
proportional, relative to the 5,508 general psychiatrists certified by the RCPSC:

This year has been an enjoyable
but busy year at the Royal College for your representatives who volunteer 100
per cent of their time to this important cause of education and establishing
the standard of the discipline. The group has been working on the new standards
for Competency by Design. Our first three-day workshop was May 1 – 3, 2018 in
Ottawa, and our second three-day workshop was Feb. 19 – 21, 2019. Please give
input to your reps on what you’d like included for future meetings.

The specialty committee is always
interested in hearing from Fellows of the Royal College and CAPL members.
We continue to work on making forensic psychiatry training high quality.

2019 CAPL Annual Conference

Is there
a better place than Montreal in the Spring? For the first time ever, Montreal
welcomes us for the 24th annual CAPL conference on Apr. 28 – May 1. The meeting
will be held at Le Westin Montreal in the historic district, within walking
distance of Notre Dame Basilica, McGill University, downtown and many other
attractions.

The
program starts on Sunday, Apr. 28 with a full day of pre-conference seminars.
In the morning, Dr. David Atwood will delve into the complexities of clozapine
with his presentation The BCDCAC’s of Clozapine (not just the ABC’s), while in
the afternoon Ms. Barbara Walker-Renshaw will ensure that we are on the right
side of the law with her presentation Recent Canadian Appellate Court Decisions
Regarding Part XX.I Review Board Matters and their Implications for Clinical
Forensic Practice. Both talks deal with issues essential to our multiple roles
in treatment, assessment and expert testimony, and both are accomplished
speakers with a wealth of information to share.

After
the pre-conference seminars finish, the conference itself gets going with
welcoming remarks and a presentation on treatment resistant depression by the
CPA president, Dr. Wei-Yi Song, after which the recipient of the 2019 CAPL
Fellowship Award will present their paper. This year the conference planning
committee was extremely pleased to receive six high quality applications for
the Fellowship Award. We won’t reveal the surprise yet, but the winning talk
will be of interest to us all. The day ends with the welcome reception, after
which people will be free to disperse to explore the city and find some of the
great food for which the city is known.

The
main program itself starts on Monday morning and runs through Wednesday with a
fascinating mix of research in progress, flash talks, debates and panel
discussions. Again, the theme of the year is abundance – we received so many abstract submissions
that the organizing committee has had to rework the schedule to accommodate all
that were accepted.

In
usual CAPL fashion, our learning is balanced with time for networking and
enjoying the company of our colleagues and friends. Monday evening sees our
annual dinner presentation, while on Tuesday evening, back by popular demand,
we have the Second Annual CAPL Pub Night, this time at L’Assommoir, an easy
stroll from our hotel. Depending on how long people stay, strolling back might
be a little more difficult.

New
this year is a special event for residents only. This will give our residents
time to meet with and ask questions of practising forensic psychiatrists with
different backgrounds and types of practice, all while enjoying a free meal
(which we all know is important during residency).

Finally,
this year we hope to roll out another initiative – the Connect Café, an opportunity
for forensic institutions, such as hospitals, correctional facilities and
outpatient programs, to meet with CAPL members and guests, including residents,
with the goal of connecting potential employers with interested professionals
considering a change in work setting. If you represent an organization that
might wish to have a booth at Connect Café, please contact Chantal Goddard or
any member of the conference organizing committee.

If you
have never been to a CAPL conference before, please join us and join in. On
behalf of the conference organizing committee, we look forward to welcoming
everybody in Montreal.

British Columbia

Between a Rock and a
Hard Place: Difficult Questions for the Psychiatric Expert

Dr. Graham Glancy and
Dr. John Bradford

One of our
members recently asked us the following question. We were at a course regarding
civil actions for PTSD in the U.S. and
the presenter emphasized that it is the
role of the psychiatric expert to come to a conclusion on causation. Is this
the case in Canada?

In Canadian courts, various
experts, most notably orthopedic surgeons and physiatrists, have in recent
years started to opine on causation. This has been the case in the United
States for some years and is becoming the trend in Canada. It is less common
for psychiatrists to give this ultimate opinion. There is no rule prohibiting
experts in Canada addressing the ultimate issue, and each judge may or may not
allow this practice. It is prudent to hesitate if asked to address this issue, so that the judge can decide whether
this is appropriate.

Causation is an issue for the
trier of fact to decide. Generally speaking in Canada most civil trials are
before a jury, and it is up to the jury to decide causation on a balance of
probabilities. The reason that an expert should not make a definitive statement
on causation is that this is a legal term of art. The Supreme Court case that
guides the courts on this matter is Athey
v. Leonati.1 Jon Athey had a particularly bad year in 1991. In
February he was involved in a motor vehicle accident, taken to the hospital and discharged home. He participated
in treatment for some time and was improving. In April of the same year a truck crossed into his lane of traffic
and hit his vehicle head-on. Following this
he continued to work full-time as a body shop manager, but could not perform
any duties involving heavy labour. He had a history of previous back problems.
Nevertheless, he made progress in treatment to such a degree that his doctor
suggested that he join a local health club and exercise. One day at the health
club he began warming up and felt a pop in his back, which turned out to be a
herniated disc. His case ended up in the Supreme Court of Canada who defined
causation, referring to well-established principles. The court ruled that the
plaintiff bears the burden of proving that the injury would not have occurred but for the wrongful act of the
defendant. Mr. Justice Major explained that where this test is unworkable, the
plaintiff must only prove that the wrongful act “materially contributed” to the
injury.2 The material contribution test can be used where it is
impossible to determine the exact cause of the injury because there are a
number of contributing causes.3 However, except for certain rare
instances where, for instance, a number of negligent acts occurred, and, were
it not for one more act, were the cause
of the injury, the but for test should
apply. It should also be noted that in a number of cases the courts have made
the point that a mere temporal relationship between the act and the symptoms
does not prove causation, and that all parties, including experts, should use
caution when coming to any conclusions just because of a temporal relationship.

In practice, the issue of
causation is a legal issue not a psychiatric issue. Therefore, the psychiatrist
should be hesitant about not opining on this issue. The psychiatric expert
should record a description of the evaluee’s account of the putative
precipitating event. Extensive collateral information is also helpful. The
expert should also attempt to delineate any psychological symptoms, and any decrease in social and occupational functioning
that may have occurred following the event. The evaluator should be alert to
any possible malingering or exaggeration. Collateral information may be helpful
in this respect. Consideration should be given to the use of psychometric
testing, including specific tests for malingering.5 The psychiatric
expert should use a biopsychosocial model, which gives a fuller view of the
evaluee. It should be noted that there is usually a multiplicity of causes that
go to the genesis of psychiatric symptoms or illnesses.

Some have considered that civil
trials should be bifurcated and that the issue of liability and damages should
be tried separately. If this were to be the case then the trier of fact would
already have decided causation, in other words the plaintiff has proven that the
injury or symptoms would not have occurred but for the tortious act. The
psychiatric expert would then be able to describe the psychiatric symptoms and
the decrease in psychosocial functioning, if any, since the act and that would
go to the assessment of damages. Regretfully bifurcation has become a dirty
word in civil law, due to the possible increased expense and logistical
problems that this procedure would create.

In summary, causation is a legal
concept, which the trier of fact decides on a balance of probabilities. In the
United States it is common for psychiatric experts to opine on this ultimate
issue, and it is becoming a trend in Canada for experts to address this
question. In many cases it is a difficult question to answer due to the
multifactorial nature of psychiatric symptomatology.

My Journey Into Forensic Psychiatry: A Resident’s Path
Into the Subspecialty

Kim Browning, MD

When I look back on my life it is
obvious that forensic psychiatry was my ultimate destination. I have always had
a fascination with the macabre; but the pinnacle event that allowed for this
fascination to take on its own life happened in 1991. I was in grade six and a
man named Jeffrey Dahmer had just been arrested for numerous atrocities
perpetrated on other men. I followed the case as part of a current events
project assigned to us by our teacher. I became utterly obsessed as to why a
human being would engage in such curious behaviours. The seed of forensics was
forever planted and a passion to acquire knowledge on the topic was ignited.

After high school, I began
postsecondary training in criminology at Douglas College, believing naively
that I could satisfy my interests through policing. It didn’t take more than
half a semester to quickly change my mind. I transferred to the University of
Victoria, certain that I wanted to pursue my interest in forensics from a
different angle. I graduated with distinction ready for the next chapter.

I went on to the University of
Calgary to do research in basic neuroscience at the Hotchkiss Brain Institute.
I completed three years of graduate school. I published my MSc thesis, but
ultimately forewent the PhD and applied to transfer to medicine.

Upon entering medical school, I
reasoned that if forensic psychiatry was my theoretical end-point, I had to
rule everything else out. While I did do some electives in forensic psychiatry,
I did most rotations in intensive care, emergency medicine and trauma. I also
explored the forensics perspective from the Medical Examiner’s office. In fact,
that was the only rotation I read an entire text book on the subject of the
rotation and for a brief time considered forensic pathology. Overall, I
thoroughly enjoyed all my time in medical school, but ultimately I knew come CaRMS
that my heart was still with forensic psychiatry; no other specialty appealed
to me in the same way.

Now I am closing out my residency
and have been offered a fellowship position at UBC for 2019. I have done many electives in forensics over the
course of my residency and I engage in resident teaching on the subject of
forensics in order to help increase exposure to the subject amongst my resident colleagues.

That is how I think the interest
in forensics begins: there is an event, a patient case or some other form of
exposure that draws someone near to the subject. Certain individuals will come
in to the psychiatric residency having already had such exposure and know from
the beginning forensics is the direction they want to pursue. But the majority
of individuals who enter into residency have not had such an experience and
therefore exposure is crucial. Regarding Royal College-certified subspecialties,
our program requires that we do no
less than six months in paediatrics, as well as geriatrics, yet there is no
mandatory time for forensics. We receive
a series of lectures in our PGY4 year and that is the only exposure one can
expect unless volitionally acquiring more. Without exposure to forensics,
recruiting becomes a problem as people will not apply to a fellowship they know
very little about. In order to increase exposure and thus interest, mandatory
rotations should be required of all psychiatric residents in forensics. It is,
after all, tested on the Royal College exams. I suggest that teaching around forensics happen in the
first two years of residency. This would provide time for residents to
contemplate and organize their future rotations.

Additionally, recruiting can be
done through presentations outlining what the career entails, along with the
benefits and drawbacks. Further, simple monthly events such as a forensic
journal club could be organized by staff or residents.

I hope to be a part of the process
of recruitment to this fascinating and rewarding subspecialty throughout my
career.

Dr. Kim Browning is a UBC PGY5
psychiatry resident who will be starting the UBC PGY6 Forensic Psychiatry
Training Program in July 2019.

CAPL BC Regional Section Update

Todd Tomita, MD, FRCPC

Chair, BC Regional Section

We continue to hold spring and
fall forensic education days at UBC Robson Square in Vancouver. Recent
participation has been between 40 to 50 people with a mix of forensic
psychiatrists, forensic psychologists, psychiatry and psychology trainees,
Crown and Defence counsel, correctional and forensic managers, and members of
the BC Review Board.

Joel Watts, MD, FRCPC, DABPN (Forensic Psychiatry)

President, CAPL-Quebec

With the annual conference coming
to Montreal this year for the first time, the Quebec chapter of CAPL sends you
our warmest bienvenu with the hope
that you enjoy everything that this cosmopolitan city has to offer.

CAPL-QC continues to represent
over 30 francophone CAPL members whose practices are vast and busy. As is the
case in many parts of the country, forensic practitioners in Quebec face a
great demand for their services and many services are actively recruiting
forensic psychiatrists to meet the demand. Having the only francophone PGY-6
forensic psychiatry residency program in Montreal is a definite advantage to
forensics in Quebec. It has already proven very been helpful in training future
forensic psychiatrists who end up replacing colleagues who are nearing or
making their way into retirement. CAPL-QC has been preoccupied by the forensic
psychiatrist resource issue for some time and this is a topic of regular
discussion at our dinner meetings near Trois-Rivières. We have been holding
these meetings biannually in this central location in the province to allow as
many of us to attend in person.

Since its inception as CAPL’s
first chapter in 2010, we continue to gather, discuss issues, share expertise
and maintain the strong tradition of collegiality and networking that has
defined not only CAPL-QC but CAPL itself over the past 20 years. Unfortunately,
due to our members’ workloads increasing because of fewer numbers of forensic
practitioners and increased clinical loads, it was difficult to have our usual
two meetings in 2018. It was nonetheless clear from our last meeting on Sept.
24, 2018 that we are committed to maintaining the strong forensic relationships
we have across the province and continue to advocate locally and provincially
for improved forensic services and practice conditions.

Fair and equitable remuneration
for forensic psychiatrists in Quebec continues to be an issue discussed
regularly, and with a new governing party in Quebec (the Coalition Avenir Québec or CAQ), time will have to tell whether any
headway can be made on this issue. We have continued our advocacy regarding
this issue with the provincial psychiatric association, the Association des
médecins-psychiatres du Québec (AMPQ).

We look forward to welcoming
catching up with as many of you as possible in Montreal in April!

Chair, Nominating Committee

The
Nominating Committee invites applications for 2019-2020 officer positions
on the Board of Directors.

In
accordance with section 7.01 of the CAPL bylaws, the officers of the Corporation are appointed by the Board. A director
may be appointed to any office of the Corporation. With the exception of the
President, Vice-President and Past-President, who must also be directors,
officers need not be directors. However, in all cases, officers must meet the
qualifications for directors outlined in section 5.03 of the bylaws. The term
of each office is one year, renewable twice for a maximum of three consecutive
one-year terms.

Current
officers are:

President: Joel Watts

Vice-President: Brad Booth

Secretary: Phil Klassen

Treasurer: Victoria Roth

Drs.
Watts, Booth and Klassen are each eligible to serve a third one-year term in
their current offices. Dr. Roth is completing a third consecutive one-year term
in the office of Treasurer, so is ineligible to be reappointed to that office.

To apply for an officer position, submit a brief statement of interest (250 words maximum) and a recent copy of your CV online at URL no later than 5:00 p.m. ET on Apr. 1, 2019. Nominations sent by email, fax or regular mail will be disqualified. The Board will appoint officers at the first teleconference meeting following the AGM, which will be chaired by the Nominating Committee Chair until the officers are appointed.